- Email: [email protected]
44. Complications Associated with Initial Management of Atlanto-occipital Dissociation with a Halo-vest Orthosis
22S
Proceedings of the NASS 22nd Annual Meeting / The Spine Journal 7 (2007) 1S–163S
contralateral side, the consequences would likely have been catastrophic. As a result, we now drill, tap, palpate, look for bleeding and routinely check post-operative CT scans. FDA DEVICE/DRUG STATUS: cervical pedicle screw: Investigational/ Not approved. doi: 10.1016/j.spinee.2007.07.050
43. Anterior Exposure of the Lumbar Spine With and Without an ‘‘Access Surgeon’’: Morbidity Analysis of 265 Consecutive Cases Claude Jarrett, MD1, John Heller, MD2, Luke Tsai, MD3; 1Emory University School of Medicine Dept. of Orthopaedics, Atlanta, GA, USA; 2 Emory University, Atlanta, GA, USA; 3Emory University School of Medicine, Atlanta, GA, USA BACKGROUND CONTEXT: With the increasing popularity of ALIFs since the release of BMP-2, and more recently the potential of artificial disc replacement, a significant increase in anterior surgical access may occur. The notion of needing an ‘access surgeon’ for such surgery has been promoted. No data exist comparing the incidence and type of exposure related complications for anterior lumbar surgery done with and without a vascular surgeon’s assistance. PURPOSE: To evaluate exposure related complications in anterior lumbar surgery with emphasis on the presence or absence of an ‘access surgeon’. STUDY DESIGN/SETTING: Independent retrospective review. PATIENT SAMPLE: 296 consecutive patients who underwent an anterior approach to only the lumbar spine from 2003 to 2005. OUTCOME MEASURES: Frequency and type of complications encountered. METHODS: Each patient’s records were reviewed for diagnosis, procedure, whether the surgical exposure was conducted by the spine surgeon (Spine) or with a vascular surgeon’s assistance (Team), levels exposed, intraoperative and postoperative complications, and any lasting sequelae. RESULTS: Overall 6% of patients encountered an intraoperative vascular complication. In comparing surgeries by Spine vs Team, the mean age of patients was 46yrs for Spine and 51yrs for Team p50.0049. The Team cohort underwent an average of 2 levels of exposure per patient, while Spine cases averaged one. The percentage of patients with at least 1 intraoperative complication was 8% and 12% for Spine and Team cases, respectively. Two percent of the Spine patients experienced an intraoperative vascular complication compared with 7% of the Team cases. Of the 21 Team exposures at L4-5, there was one intraoperative vascular complication, compared with 2 of 65 Team approaches at L5-S1. No intraoperative vascular complication occurred in the 50 single level Spine exposures. Four percent of the 93 patients with single level exposures with Team approaches sustained an intraoperative vascular complication. There were 14 arterial or venous injuries appreciated intraoperatively in a total of 13 patients. These vascular injuries were directly repaired in 10 patients without any residual sequelae. The rate of vascular complications was statistically higher for multiple level exposures 9% vs single level exposure 3% p50.0357. Eight percent of the 13 multi-level Spine cases sustained an intraoperative vascular complication, while 9% of the 109 multi-level Team exposures had vascular complications. The rate of erectile dysfunction and retrograde ejaculation was found to be 6% in our study. When evaluating Spine versus Team approaches, 6% in the Spine cases while 7% in the Team approach expressed retrograde ejaculation. CONCLUSIONS: Complications can be anticipated to occur with anterior lumbar surgery, and they vary with the anatomic level exposed, the number of levels exposed, etc. The type and frequency of such complications is reasonably well understood. However, the results of this study do not support the notion that the presence of an ‘access surgeon’ is either essential or that such assistance will change the type and rate of complications. With adequate training and judgment, spine surgeons may safely perform such exposures, provided vascular surgical assistance is readily available. Our data further indicate that selective recruitment of surgical assistance has been used for those cases in which exposure difficulties are anticipated.
FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. doi: 10.1016/j.spinee.2007.07.051
44. Complications Associated with Initial Management of Atlantooccipital Dissociation with a Halo-vest Orthosis Christopher Chaput, MD1; 1Scott & White Hospital, Texas A&M HSC, Temple, TX, USA BACKGROUND CONTEXT: Atlanto-Occipital Dissociation (AOD) is recognized as an extremely unstable injury pattern with a high mortality rate. Occipito-Cervical Instrumentation (OCI) is accepted as the standard definitive treatment for this injury. However, injuries associated with AOD can delay or prevent definitive fixation, and some texts recommend immediate placement of a halo-vest in these cases. PURPOSE: Document halo-vest related complications in the setting of AOD in comparison to complications sustained by patients not treated in a halo-vest STUDY DESIGN/SETTING: Retrospective chart and radiographic review PATIENT SAMPLE: All patients at a Level 1 trauma center diagnosed with AOD in 2003–2006. OUTCOME MEASURES: Radiographic loss of reduction, clinical complications. METHODS: An institutional database was reviewed to locate all 6 patients diagnosed with AOD. Computer tomograms (CT) taken at presentation were available for all patients. AOD was defined as having a basion to dens distance of O10mm and the presence of subluxation/distraction at the occipital condyle-C1 articulation, resulting in one exclusion. Hospital charts, clinic charts, imaging (radiographs, CT scans and MRI) were reviewed. RESULTS: All three patients who received halo-vest treatment had significant complications (Table 1). No complications were attributable to posterior open reduction internal fixation. CONCLUSIONS: Halo-vest placement can cause significant complications when used acutely for AOD, and does not necessarily improve reduction. Routine use of the halo-vest for even temporary treatment of AOD should be questioned. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. doi: 10.1016/j.spinee.2007.07.052
45. Predicting Postoperative C5 Nerve Palsy: The Terrible Triad Thomas Mroz, MD1, Edward Benzel, MD2, Jeffrey Wang, MD3; 1Cleveland Clinic Foundation, Cleveland, OH, USA; 2Cleveland, OH, USA; 3 University of California, Los Angeles, Santa Monica, CA, USA BACKGROUND CONTEXT: Postoperative C5 palsy (C5P) is reported to occur in an average of about 5% of patients after surgery for cervical compression myelopathy, without significant differences between anterior or posterior surgery. Multiple theories explaining C5P have been postulated, but none have been proven. Predisposing risk factors are not known. PURPOSE: To determine if sagittal diameter, foraminal diameter, and the cord – lamina angle (CLA) are associated with post-operative C5P. STUDY DESIGN/SETTING: Retrospective radiographic review. PATIENT SAMPLE: 78 patients with cervical spondylotic myelopathy that underwent decompressive surgery involving the C4-5 level; 30 patients underwent anterior surgery, and 48 patients had posterior surgery. Seven patients had post-operative C5Ps, 3 from an anterior approach. OUTCOME MEASURES: n/a. METHODS: The C4-5 axial T2 weighted image of all patients was digitalized. On all patients, the midline canal diameter, the foraminal diameters and the left and right cord-lamina angles were measured using
Proceedings of the NASS 22nd Annual Meeting / The Spine Journal 7 (2007) 1S–163S
contralateral side, the consequences would likely have been catastrophic. As a result, we now drill, tap, palpate, look for bleeding and routinely check post-operative CT scans. FDA DEVICE/DRUG STATUS: cervical pedicle screw: Investigational/ Not approved. doi: 10.1016/j.spinee.2007.07.050
43. Anterior Exposure of the Lumbar Spine With and Without an ‘‘Access Surgeon’’: Morbidity Analysis of 265 Consecutive Cases Claude Jarrett, MD1, John Heller, MD2, Luke Tsai, MD3; 1Emory University School of Medicine Dept. of Orthopaedics, Atlanta, GA, USA; 2 Emory University, Atlanta, GA, USA; 3Emory University School of Medicine, Atlanta, GA, USA BACKGROUND CONTEXT: With the increasing popularity of ALIFs since the release of BMP-2, and more recently the potential of artificial disc replacement, a significant increase in anterior surgical access may occur. The notion of needing an ‘access surgeon’ for such surgery has been promoted. No data exist comparing the incidence and type of exposure related complications for anterior lumbar surgery done with and without a vascular surgeon’s assistance. PURPOSE: To evaluate exposure related complications in anterior lumbar surgery with emphasis on the presence or absence of an ‘access surgeon’. STUDY DESIGN/SETTING: Independent retrospective review. PATIENT SAMPLE: 296 consecutive patients who underwent an anterior approach to only the lumbar spine from 2003 to 2005. OUTCOME MEASURES: Frequency and type of complications encountered. METHODS: Each patient’s records were reviewed for diagnosis, procedure, whether the surgical exposure was conducted by the spine surgeon (Spine) or with a vascular surgeon’s assistance (Team), levels exposed, intraoperative and postoperative complications, and any lasting sequelae. RESULTS: Overall 6% of patients encountered an intraoperative vascular complication. In comparing surgeries by Spine vs Team, the mean age of patients was 46yrs for Spine and 51yrs for Team p50.0049. The Team cohort underwent an average of 2 levels of exposure per patient, while Spine cases averaged one. The percentage of patients with at least 1 intraoperative complication was 8% and 12% for Spine and Team cases, respectively. Two percent of the Spine patients experienced an intraoperative vascular complication compared with 7% of the Team cases. Of the 21 Team exposures at L4-5, there was one intraoperative vascular complication, compared with 2 of 65 Team approaches at L5-S1. No intraoperative vascular complication occurred in the 50 single level Spine exposures. Four percent of the 93 patients with single level exposures with Team approaches sustained an intraoperative vascular complication. There were 14 arterial or venous injuries appreciated intraoperatively in a total of 13 patients. These vascular injuries were directly repaired in 10 patients without any residual sequelae. The rate of vascular complications was statistically higher for multiple level exposures 9% vs single level exposure 3% p50.0357. Eight percent of the 13 multi-level Spine cases sustained an intraoperative vascular complication, while 9% of the 109 multi-level Team exposures had vascular complications. The rate of erectile dysfunction and retrograde ejaculation was found to be 6% in our study. When evaluating Spine versus Team approaches, 6% in the Spine cases while 7% in the Team approach expressed retrograde ejaculation. CONCLUSIONS: Complications can be anticipated to occur with anterior lumbar surgery, and they vary with the anatomic level exposed, the number of levels exposed, etc. The type and frequency of such complications is reasonably well understood. However, the results of this study do not support the notion that the presence of an ‘access surgeon’ is either essential or that such assistance will change the type and rate of complications. With adequate training and judgment, spine surgeons may safely perform such exposures, provided vascular surgical assistance is readily available. Our data further indicate that selective recruitment of surgical assistance has been used for those cases in which exposure difficulties are anticipated.
FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. doi: 10.1016/j.spinee.2007.07.051
44. Complications Associated with Initial Management of Atlantooccipital Dissociation with a Halo-vest Orthosis Christopher Chaput, MD1; 1Scott & White Hospital, Texas A&M HSC, Temple, TX, USA BACKGROUND CONTEXT: Atlanto-Occipital Dissociation (AOD) is recognized as an extremely unstable injury pattern with a high mortality rate. Occipito-Cervical Instrumentation (OCI) is accepted as the standard definitive treatment for this injury. However, injuries associated with AOD can delay or prevent definitive fixation, and some texts recommend immediate placement of a halo-vest in these cases. PURPOSE: Document halo-vest related complications in the setting of AOD in comparison to complications sustained by patients not treated in a halo-vest STUDY DESIGN/SETTING: Retrospective chart and radiographic review PATIENT SAMPLE: All patients at a Level 1 trauma center diagnosed with AOD in 2003–2006. OUTCOME MEASURES: Radiographic loss of reduction, clinical complications. METHODS: An institutional database was reviewed to locate all 6 patients diagnosed with AOD. Computer tomograms (CT) taken at presentation were available for all patients. AOD was defined as having a basion to dens distance of O10mm and the presence of subluxation/distraction at the occipital condyle-C1 articulation, resulting in one exclusion. Hospital charts, clinic charts, imaging (radiographs, CT scans and MRI) were reviewed. RESULTS: All three patients who received halo-vest treatment had significant complications (Table 1). No complications were attributable to posterior open reduction internal fixation. CONCLUSIONS: Halo-vest placement can cause significant complications when used acutely for AOD, and does not necessarily improve reduction. Routine use of the halo-vest for even temporary treatment of AOD should be questioned. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. doi: 10.1016/j.spinee.2007.07.052
45. Predicting Postoperative C5 Nerve Palsy: The Terrible Triad Thomas Mroz, MD1, Edward Benzel, MD2, Jeffrey Wang, MD3; 1Cleveland Clinic Foundation, Cleveland, OH, USA; 2Cleveland, OH, USA; 3 University of California, Los Angeles, Santa Monica, CA, USA BACKGROUND CONTEXT: Postoperative C5 palsy (C5P) is reported to occur in an average of about 5% of patients after surgery for cervical compression myelopathy, without significant differences between anterior or posterior surgery. Multiple theories explaining C5P have been postulated, but none have been proven. Predisposing risk factors are not known. PURPOSE: To determine if sagittal diameter, foraminal diameter, and the cord – lamina angle (CLA) are associated with post-operative C5P. STUDY DESIGN/SETTING: Retrospective radiographic review. PATIENT SAMPLE: 78 patients with cervical spondylotic myelopathy that underwent decompressive surgery involving the C4-5 level; 30 patients underwent anterior surgery, and 48 patients had posterior surgery. Seven patients had post-operative C5Ps, 3 from an anterior approach. OUTCOME MEASURES: n/a. METHODS: The C4-5 axial T2 weighted image of all patients was digitalized. On all patients, the midline canal diameter, the foraminal diameters and the left and right cord-lamina angles were measured using